Provider Demographics
NPI:1376621771
Name:KENNETH R. HAUSWALD
Entity Type:Organization
Organization Name:KENNETH R. HAUSWALD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:HAUSWALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-920-9813
Mailing Address - Street 1:400 SAINT CHRISTOPHER DR
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7022
Mailing Address - Country:US
Mailing Address - Phone:606-833-0088
Mailing Address - Fax:606-833-0130
Practice Address - Street 1:400 SAINT CHRISTOPHER DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7022
Practice Address - Country:US
Practice Address - Phone:606-833-0088
Practice Address - Fax:606-833-0130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY16406208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0385104Medicaid
KY000000215221OtherANTHEM BC/BS
KY64164064Medicaid
OH0385104Medicaid
KY000000215221OtherANTHEM BC/BS
KY=========OtherTAX ID